A5503 Diabetic shoe w/roller/rockrFor diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe
Status X: statutory exclusion, not paid under the PFS.
3 of 3 payer prior-auth lists that name A5503 require prior authorization or set conditions: Blue Cross Blue Shield of Arizona (AZ Blue), Passport by Molina Healthcare (Kentucky), UnitedHealthcare Community Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) | |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth under conditions | State exception; PA above quantity limits | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
A5503 appears in 3 coverage policies from Aetna, Anthem, Cigna.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Foot Orthotics (0451) | covered if criteria are met (range A5500-A5507) | Jul 16, 2026 | payer document |
| Anthem | Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes (CG-DME-19) | covered if criteria are met | Nov 6, 2025 | payer document |
| Cigna | Orthotic Devices and Shoes (0543) | covered if criteria are met | Sep 15, 2026 | payer document |
Prior authorization required or conditional in IL, KY, LA, MA, NY, OH, WV.
From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.